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Customer Service Insurance

Location:
Irving, Texas, United States
Posted:
October 28, 2018

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Resume:

Koteswara Rao

ac7i8n@r.postjobfree.com

+1-214-***-****

Profile

* ***** ** ** ******** experience worked as a Pega Senior Developer in the areas of design, development, testing,. Have close to 4+ years of experience in PEGA Practices, certified as CSSA.

Proficient in requirements gathering, specification writing, enhancement/problem analysis, problem resolution, coding, testing and full life cycle of migration and implementation.

Good hands on experience in implementation of Declarative Processing features - Expressions, Constraints, On Change, Decision Rules like Decision Table, Decision Map etc.

Extensive debugging skills in PRPC using TRACER, Clipboard, and Rule Inspector

Designed PRPC flows, Assignment, utilities, Decision, Spin-off and Split- Join shapes. Well-versed in PRPC flows, interpretation of all Flow Shapes

Expertise in PRPC integration services Rule-Connectors and Rule-Services, activity creation, validate Rule Types such as Rule-Obj-Validate, Rule-Edit-Validate

Worked on Agents, SLA, and UI rules

Expertise in developing User Interfaces, screen layout using Harness, Section. Extensive familiarity in Decision, Process, Technical, SysAdmin Categories of rules

Experience in Creating Decision Rules like Decision Tree, Decision Table, Map Value and When Condition, activities, edit input, Obj-validations

Thoroughly worked on reporting wizard, list view, summary view, activities, Obj-Validation.

Work exposure on Integration (SOAP, REST, SQL) with PRPC.

Good communication skills, interpersonal skills, self-motivated, quick learner, team player.

Certifications:

PEGA Certified Senior System Architect PRPC

PEGA Certified System Architect PRPC

Skill Set

PEGA:

Expertise in

PEGA PRPC V7.2, V7.1, V6.2, JAVA/J2EEE

Application Server

Apache Tomcat 5.5/6.0, Web Sphere

Databases

Oracle9i, MySQL

Operating Systems

Windows 2000/XP/Vista/7/8, Linux CentOS/ RHEL6, Mac OS X, OS/400

Methodologies

Agile, Scrum, Design Patterns

AS/400:

Languages : RPG/400, ILE-RPG, SQLRPG, CLLE, CLP. ILE free format, SYNON, Core Java

DBMS : DB2/400, QUERY/400

Operating System : OS/400, Windows 98, XP

Tools : Jira, SDA, ALDON, ABSTRACT, ROBOT, HPSM, HPQC,SYNON

Other Skills : MQ Series, Tivoli Workload Scheduler, XML parsing, Web Services.

Domain Knowledge : Healthcare PBM(RxCLAIM), Manufacturing, Telecom

Education:

Master of Computer Applications, Osmania University.

Bachelor of Computer Science, Nagarjuna University.

Professional Experience:

Anthem Inc., Atlanta, GA Pega Sr. Developer. Dec 2017 – Till Date

Anthem, Inc . is an American health insurance company founded in the 1940s, prior to 2014 known as wellpoint, inc. It is the largest for-profit managed health care company in the Blue Cross and Blue Shield Association.

It handles huge amount of provider data though applications SPS and PLM.

PLM- Provider Lifecycle Management.

From Anthem perspective, a Provider is an entity that renders a medical service for our members.

This includes Physicians, nurse practitioners, physician assistants, medical groups, hospitals, clinics,

diagnostic labs, ambulance services.

PLM manages all change requests for provider data by creating work objects and routing to appropriate

associates.

SPS - Strategic Provider Solutions.

SPS provides single source of truth for provider administration with standardized UI across all markets

Increased automation throughout the provider life-cycle with workflow and built in data governance and quality rules

Streamlined ability for provider self-service.

scalable architecture that supports anthem and future growth.

clarity of purpose within components that simplify design.

Responsibilities:

Interacted with Business users to understand expectations and requirements PEGA PRPC Technical design and configuration against documented requirements for the PRPC application.

Worked on developing enhancements provided by CMS and maintaining existing PEGA PRPC Applications.

Worked on modifying certain Activities to Data Transforms as per PEGA Guardrails.

Attended Business meetings to discuss and finalize the CMS PEGA Mandate tasks.

Implemented routing logic to newly added stated based on defined criteria.

Involved in upgrading List Views to Report Definitions.

Involved in skimming the rules to highest ruleset versions.

Extensively using Tracer, Clipboard tool and Rule Inspector to perform unit testing during Application development and debugging.

Created Agents to automate the weekly basis Reports for Work Managers.

Worked on modifying and adding new Word Templates to PEGA upon Business request.

Involved in CMS Retention Plan Meetings with Product Owners and helped them in providing Data Definitions.

Involved in redesigning the existing flow by adding new Flow Actions, Sections, SLA and Correspondences.

Automated the Letter delivery functionality to the Providers which improved the productivity of the Work Users.

CVS Caremark, Richardson, TX CVS Health Inc. Jun 2016 – Dec 2017

CVS Health (previously CVS Corporation and CVS Caremark Corporation) is an American retail pharmacy and health care company headquartered in Woonsocket, Rhode Island.

CVS Caremark provides comprehensive prescription benefit management services including mail order pharmacy services, specialty pharmacy and infusion services, plan design and administration, formulary management and claims processing. The company’s clients are primarily employers, insurance companies, unions, government employee groups, health plans, Managed Medicaid plans and other sponsors of health benefit plans and individuals throughout the United States.

Project # PAS (Prior Authorization System) Duplicate Check

Description: The Prior Authorization System (PAS) is used to process member and provider requests for a member to receive a medication that is not on the member’s formulary. Prior Authorizations can be initiated by a member or by a provider.

Currently, issues are encountered when a user enters a new case and does not merge the cases when a duplicate case is found. There is no way for the system to catch these duplicate cases after the fact. Not catching these duplicate cases results in inappropriate reopening, incorrect denials, and missed turnaround times.

This change is for adding measures to the PAS system to prevent incorrectly processed redeterminations by catching duplicate cases as they are entered. Incorrectly processed redeterminations may result in Medicare Corrective Action Plans up to and including sanctions.

Responsibilities:

Interacted with Business users to understand expectations and requirements PEGA PRPC Technical design and configuration against documented requirements for the PRPC application.

Generated List and Summary reports and enabled security levels on the reports so that particular access group can view them

Created Rules for Validation, Integration rules like Rule-RDB-SQL using methods like OBJ Save, OBJ Open, RDB List, Creation of Work Objects, assigned to Operators

Developed Portals, Gadgets as per the client's requirement created simple to complex Activities using page-new, page-copy, page-merge-into, properties-set etc.

Involved in the SOAP service for the service Request and WSDL deployment

Performed integration by developing rules pertained to rule-connect and rule-service. Major tasks involved integrating with SQL databases to fetch data and with SOAP/ Web services to review particular data

Involved in making changes and adding new parameters to the already existing Functions

Created the File Listeners to copy the XML files from a shared location to temporary folders

Used the TRACER to examine the rules and to minimize the execution time Performance test of all activities and rules using PRPC-PAL Tool.

Participated extensively in designing application security which involves setting up Access groups, Access Roles, Operators, Application ID, Org Divisions, Org Units and Work groups

Extensively worked on writing activities for Validations and Error Handling.

Involved in conducting Unit testing, Regression testing, Integration testing, System testing Performance testing and End-to-End testing

Prepared Technical and Conceptual Design documentation and Estimation hours for the modules

Involved in Bug Fixing Activities for Harness, Declare Expression and When Rules

NetCracker, Cincinnati Consultant Jul, 2013 – Apr, 2016

Project #1 : KIS

Description: This is a General Insurance project, intended to do the underwriting job of an insurance company whereby the auto insurance policies are generated. The client approaches the company for auto insurance cover; A proposal form has to be issued by the employee of the insurance company who is called an underwriter. The proposal form has to be filled by the client in full, which gives the details about the type of insurance cover required by the client and details regarding the vehicle. The underwriter calculates the insurance premium and conveys to the client and if he accepts and pays the premium through cash/card, policy is to be issued and records to be updated accordingly. Also further proceedings with each client are to be maintained in the system.

Responsibilities:

Involved in developing process flows, activities, User Interface Rules

Involved in analyzing functional requirements. Created technical documents for Flows and Flow Actions.

Involved in updating and developing Process flow, Activities and UI properties.

Created Decision Rules and Declarative Expressions as per the requirements.

Created Rules for Validation, Integration rules like Rule-Connect-SQL using methods like RDB save, RDB Open, RDB list, Creation of Work Objects, assigned to Operators.

Used Connector Rules

Worked in Parsing of XML Requests and XML Steaming.

Worked on PAL to find performance issues.

Implemented Complex User Requirements Using Tree Grids, along with harness, Flow actions and Sections.

Wrote SLAs to show the assignment on the exception case to resolve the case

Created Decision Rules (When condition Rules, Decision Tree Rules, Decision Table Rules and Map Value Rules) and Declarative Expressions as per the requirements.

Created Validate Rules for User Interface.

Incorporated sections and layouts in flow actions and harness.

Environment: Pega Rules Process commander V 6.2,V7.1, SQL, Windows, MS Visio 2003, AS 400

Project #2 CSQA (Customer Service Quality Audit) :

Description: The purpose of this project is to leverage PEGA PRPC to automate the current Customer Service data quality auditing processes for audits. This project will provide real time tracking of any discrepancies in these audits. Audit results will be available to the users in real time.

Responsibilities:

Daily interaction with client to define and gather business requirements and providing appropriate technical consultancy

Involved in analyzing functional requirements. Created technical documents for Flows and Flow Actions

Created rules like properties and activities for the concerned classes.

Involved in creating user interface through Harness and Section rules .

Involved in updating and developing Process flow, Activities and UI properties.

Created Decision Rules and Declarative Expressions as per the requirements.

Created Report Definition for the reporting purpose in the process commander.

Involved in testing of Application using PRPC tools like Rules Inspector, Clipboard and Tracer.

Worked in Parsing of XML Requests and XML Steaming.

Implemented Complex User Requirements Using Tree Grids, along with harness, Flow actions and Sections.

Wrote SLAs to show the assignment on the exception case to resolve the case

Involved in Technical documentation and testing different scenarios viz..

Involved in fixing defects.

NetCracker Tech., Orlando Florida System Analyst May, 2012 – Jun 2013

NetCracker Technology is the proven partner for communications service providers and cable operators, offering comprehensive, end-to- end BSS, OSS, and Enterprise Applications supported by extensive delivery capabilities to optimize their business

Roles and Responsibilities:

Principal responsibility will be ensuring nightly and billing and month end processing is completed per established service level agreements for all clients.

The Production Control Analyst will be the first level (Tier 1) contact for problems encountered within the customer batch cycles.

Providing the problem analysis and escalation to the ICOMS Support Team for any issues encountered within the batch cycles.

Should be able to support in shifts on 24/7 basis.

Worked on Network Inventory Management(NIM) maintenance.

Having effective and efficient communication under stressful environment.

Worked on Telephony module and NIM system .

Responsible for executing, monitoring, troubleshooting and reporting on production jobs.

Critical processes based on shift checklists and clearly defined procedures and policies.

Respond to the Production group and Sev1 group support tickets, which are assigned to the Technical Services team.

Monitor and execute trouble escalation procedures in support of core data center support systems.

Execute and monitor EOD, EOW and EOM production job streams in support of company’s primary applications.

Monitor and execute trouble escalation procedures in support of core operating processes and applications.

Takes the ownership and responsibility of cases while escalating whenever appropriate.

Demonstrates the ability to work flexible hours, alternate shifts and the ability to carry a pager as required by support team.

Environment: OS/400, RPG400, RPGLE, ILE, Free-format, COBOL/400, CL/400, CLLE, DB2/400, SQL, SQL/400, XML, PDM, SEU, DFU, SDA, EZVIEW, WRKQRY, ROBOT, Job scheduler, Web Services, Change Managements software’s too - ALDON. Web Desk for ticketing tool. QC for defect tracking tool. PCR for any emergency fixes.

Convergys India Pvt. Ltd., India Software Engineer Sep, 2008 – May, 2012

Icoms is one system that can handle everything from billing to provisioning and scheduling on the one system.Various functionalities with in ICOMS is customer service, service order, Billing, fault managements inventory management disputes management and so on.

ICOMS is the most open customer management system available. Users have access to every field of information in every file in their database. It is an End-to-End billing for Cable, Telephone, Call card service, Fast data…Etc.

Roles and Responsibilities:

Participated in Client requirement meetings for requirement gathering.

Worked on low level and high-level technical documentation.

Created High level and detailed level design documents based on the BR's and FR's.

Planning & Analysis Meetings for any new requirements and co-ordination with Business.

Working on complex configuration, scripting to achieve the functionality as per the client requirement

Working on Design and development of various modules of the Project like Activities, Accounts, Contacts, and Time Off Territory

Developed and configured various Dashboards, Custom Reports and Report Folders for different user profiles based on the need in the organization.

Perform administration tasks as needed, managing custom fields, integration and data cleanup

Created workflow rules and defined related tasks, email alerts, and field updates.

Developed custom search functionality for accounts and contacts using SOSL

Involved in using SOQL using force.com explorer

Developed Apex Classes, Controller Classes and Apex Triggers for various functional needs in the application.

Performed customizations by creating the Custom profiles, Fields, Dependent pick-lists, Page Layouts, Record Types, Objects, Tabs.

Worked on LOV's, Views, Responsibilities

Worked on role hierarchy & sharing rules to configure visibility

Worked on workflow rules & approval processes.

Worked on bug fixes of the Application.

Environment: OS/400, RPG400, RPGLE, ILE, Free-format, COBOL/400, CL/400, CLLE, DB2/400, SQL, SQL/400, XML, PDM, SEU, DFU, SDA, EZVIEW, WRKQRY, ROBOT, Job scheduler



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